Australia formally adopted the metric system of measurement in 1971. Before that, the British Imperial system of measurement was in common use, with such units as ounces and pounds for mass; and yards and miles for length. Yet, even prior to 1971, some areas of medicine and science were beginning to adopt metric units, due to the obvious advantage of operating in base 10.
The imperial measurement system falls under a broader system called avoirdupois. Avoirdupois is derived from Old French, meaning “goods of weight”. The first trace of such a system seems to have originated in England circa 1300, and was used for weighing wool. Over the centuries, many variations in measurement systems evolved. These differed between countries (even regions), and industries.
One sub-set of the avoirdupois system, was the Apothecaries’ system of measurement, used in drug dispensing. (Apothecary is an historical term for a person we would now call a pharmacist.)
The Apothecaries’ units of measurement for weight included the – grain, scruple, drachm, ounce, and pound.
The smallest unit – the grain – was based on the mass of an ideal single grain of barley. It was equivalent to 64.79891 mg in the current metric system. Most drug prescriptions were written with grains as the dose unit to be given.
Consider the following pre-medication order, written on an anaesthetic record in 1944. The prescription is morphine 1/6 grain, and atropine 1/100 grain, both to be given IM three quarters of an hour preoperatively. Can you work out the milligram equivalents for the morphine and atropine, based on the conversion factor above?
The anaesthetic would have been induced and maintained with ether. Can you think of any advantages and disadvantages of the morphine pre-med? Why do you think the atropine was necessary?
The Laryngeal Mask Airway (LMA) was just one of numerous patents that Brain applied for. This is true. The LMA was the thirteenth patent he applied for. While not gifted in the sciences at school he had a flair for construction. He built his own guitar at the age of fourteen.
The first published study involving the LMA was a case series of women undergoing gynaecological laparoscopy. This is also true. The paper was published in the BJA in 1983 and was titled “The laryngeal mask- a new concept in airway management”.
The LMA was first commercially available in 1983. False. The first commercial devices were available in the UK in 1988. Not all that long ago really! It took years for Brain to perfect his device and develop it as a medical device.
Australia was the first place to use the Proseal LMA. This is true and was again relatively recently in 2000. I don’t know why. Perhaps he knew he had a willing advocate down under in the person of Joe Brimacombe!
There are over twenty different methods described to insert a LMA. This is true and they are all described in Brimacombe’s book. You only need one, however.
Dr Brain was born on July 2, 1942. His father was a diplomat and was knighted. Surely his son deserves a knighthood also?
I hope I am not being presumptuous in assuming that all of you know who Archie Brain is. The next sentence will give you a rather substantial clue regardless. I reckon his invention of the laryngeal mask was worthy of the Nobel Prize for Medicine. His invention is certainly the most significant advance in the field of anaesthesia for my generation. It is very fortunate that propofol joined the arsenal at roughly the same time. White stuff + LMA is probably the commonest anaesthetic combo in the world today. Interestingly enough the first anaesthetics using the LMA were done with a combination of thiopentone and muscle relaxant. Trying to insert a LMA with just thiopentone is fraught with peril but the contemporary anaesthetic trainee has barely seen a vial of thiopentone these days let alone tried to insert a LMA under the influence of this venerable barbiturate. For a fascinating and comprehensive history about all things concerning Brain and his invention one should consult Joe Brimacombe’s definitive Laryngeal Mask Anesthesia: Principles and Practice. I would confidently assert that Brimacombe has inserted more LMAs than anyone else on the planet. Despite the American spelling of his textbook he is a pom who practices in Far North Queensland. To say he is an ardent fan of the Proseal LMA would be an understatement. LMAs are so popular in Cairns that they mandate intubating people each April so they don’t forget what to do with a laryngoscope.
The Laryngeal Mask Airway (LMA) was just one of numerous patents that Brain applied for. TRUE/ FALSE
The first published study involving the LMA was a case series of women undergoing gynaecological laparoscopy. TRUE/ FALSE
The LMA was first commercially available in 1983. TRUE/ FALSE
Australia was the first place to use the Proseal LMA. TRUE/ FALSE
There are over twenty different methods described to insert a LMA. TRUE/ FALSE
Still in holiday snap mode, but also anaesthesia history mode. Not examinable but here’s an opportunity to be sucked into the maw of wikipedia should you wish some guilt free distraction from study…
Simpson is credited with introducing chloroform as an anaesthetic agent for humans TRUE/FALSE
Simpson made important developments in obstetric forceps TRUE/FALSE
The first recorded use of chloroform for anaesthesia was direct injection into a dog TRUE/FALSE
The first recorded death from chloroform was a 75 year old woman TRUE/FALSE
Simpson removed the handle of the Broad St pump TRUE/FALSE
During your working lifetime, drugs and their indications for usage will change many times. The point of the Part I is not to teach you everything you need to know, but rather how to assess new changes and techniques as they become popular. Be particularly aware of the unforeseen consequences.
Imagine Dr House using hydrocodone for aching muscles! None of us would ever make that mistake.
T/F Opiates are highly effective for chronic pain
T/F Oxycontin provides effective analgaesia for twelve hours
I have collected a few advertisements to show you what people will think of your practice in 50 years.
Grumpy surgeons? Put Lithiated 7up in the tea room to take the “ouch” out of grouch
Do you find yourself drowsy on the afternoon list? Try the nerve stimulant properties of the Coca plant.
When Coca-Cola isn’t enough, Ritalin usually brings relief with the very first dose.
Kids not sleeping? A Nembutal suppository will soon set them right.
When coughing keeps the whole family awake, reach for Heroin Hydrochloride
Don’t let your children suffer through the pain of teething. Cocaine toothache drops provide an instantaneous cure.
Weight loss need not be a problem with amphetamine.
Reserpine: The natural therapy for ADHD
Last week I advised a rather algorithmic SAQ approach of thinking of and writing relevant facts. Excellent candidates however are already writing and succinctly explaining relevant facts because they understand the material well enough to distil out what is important. Oliver Wendell Holmes coined the term ‘simplicity beyond complexity’ which is where you want to aim for – to understand the material well enough to know what’s important, sum it up and explain it. If you’ve not heard of Oliver Wendell Holmes before then read Letter to Dr Morton.
Today is a very significant one particularly if you are an anaesthetist. On this day, 171 years ago, William Thomas Green Morton (pictured above) administered the first successful anaesthetic publically at what is now termed the ‘Ether Dome’ in Massachusetts General Hospital, Boston. I am biased but think this is the most significant medical discovery ever. What is perhaps surprising is that the demonstration didn’t happen many years earlier- ether is not a novel chemical nor is it difficult to synthesize. The analgesic and sedative properties of nitrous oxide had been known about for almost half a century but no one had bothered to apply this knowledge to the more expedient need of surgical anaesthesia. To be fair, Morton’s contemporary, Horace Wells, used nitrous oxide successfully for dental extractions before unfortunately ‘failing’ when he demonstrated it publically on the same stage as Morton would subsequently have success. I put the ‘failing’ in apostrophes because although Wells’ patient (he was a medical student with a toothache) groaned when under the influence- eliciting the derisory, “Bah humbug!” comment from the surgeon- the patient later stated that he did not recall the procedure and that it had caused him no pain. Surgeons have forever since equated movement or vocalisation from the patient as evidence of inadequate anaesthesia.
Although we commemorate this event with the respect that it deserves, the pioneering anaesthetists of the day were not the most respectable or reputable bunch. For the most part they were greedy, self-serving dentists out to make a quick buck. Nonetheless we are indebted to them.
The following statements relate to October 16, National Anaesthesia Day:
It has always been celebrated on this date in Australia TRUE/FALSE
Morton tried to patent ether calling his mystery drug ‘Letheon’ TRUE/FALSE
Morton was running late on the momentous day setting an unfortunate precedent TRUE/FALSE
Morton was the first person to administer ether successfully for a surgical procedure TRUE/FALSE
Morton killed himself by cutting his femoral artery at the age of 48 while imprisoned. He was incarcerated for throwing acid in a prostitute’s face TRUE/FALSE
Answers another time. Happy Anaesthesia Day!
Some answers for you. Again these mostly come from Dr Wilson’s “One Grand Chain”.
The first anaesthetic for a surgical procedure was given by William Ross Pugh in June, 1847 at Launceston. This is probably true and the actual date was the 7th of June. The patient was a woman with a mandibular tumour. Seems this is a popular condition to have treated under historically significant anaesthetics- Morton anaesthetized Gilbert Abbott who also had a lump in his neck. There is a statue of Pugh in Launceston that commemorates the event. There is reasonable evidence to suggest that Pugh wasn’t a properly qualified medical practitioner.
The first anaesthetic given in Australia was also by William Ross Pugh. This is probably true. Pugh’s anaesthetics are the best documented but there are a couple of other contenders for the title. Of these a Sydney dentist named John Belisario has the best case to challenge Pugh. Interestingly both men gave anaesthetics on the 7th June, 1847!
The pioneering anaesthetists would have had to make their own ether. This is true and it is not hard to do.
The first case of awareness under anaesthesia is also attributed to Pugh. This is true regarding anaesthetics administered in Australia. Pugh anaesthetized three patients on 7th June (attempted to actually, the third case was a failure due to equipment issues). The second patient had a cataract removed and was aware but didn’t report it to be painful. The first case of anaesthetic awareness occurred with the iconic first ‘successful’ demonstration of ether by Morton on 16 October, 1846. The patient, Gilbert Abbott, later reported being aware of the procedure and that it was indeed painful. Presumably it would have been a lot worse if he’d had no ether at all!
The first reported anaesthetic death in Australia is also attributed to Pugh. This is false. The first reported anaesthetic death was in April 1848. Like most ‘anaesthetic’ deaths there were several other contributing factors. The unfortunate patient was a middle aged woman named Ann Ryder who suffered two indignities on that fateful day: she was tossed from a carriage and sustained a compound fracture of the leg and she was also robbed. She was given ether and had her leg amputated. She briefly regained consciousness after the procedure but then became obtunded and was unable to be resuscitated. Pouring brandy down an obtunded person’s throat was a popular resuscitative measure at the time. It didn’t work in this instance.
No LO for this stuff but pretty interesting nonetheless. If you can’t be bothered to google the answers I will give them to you in a subsequent post. I am pretty biased but I think Morton’s successful public demonstration of general anaesthesia using ether on 16th October 1846 is the single most important medical discovery of the modern era. It is astonishing given the lack of social media and communication satellites in the 1840s that within months doctors were trying their hand at giving ether anaesthetics on the other side of the world including Australia. Indeed the first anaesthetics in Australia were given in June 1847. The apparatus used was based on a picture in a London newspaper published in January 1847. It took four months to sail from London to Australia so it was only a matter of weeks from reading about Morton’s discovery that Australians were giving it a crack. I don’t think many of us would try a novel technique on a patient that we’d only read about in a journal, especially when we needed to fashion our own apparatus!
The statements relate to historically significant events regarding anaesthetic practice in Australia. The definitive resource on Australian anaesthetic history is Gwen Wilson’s “One Grand Chain: The History of Anaesthesia in Australia”. Not a bad read. I got my copy gratis from the nice folk at the College library.
The first anaesthetic for a surgical procedure was given by William Ross Pugh in June, 1847 at Launceston. TRUE/ FALSE
The first anaesthetic given in Australia was also by William Ross Pugh. TRUE/ FALSE
The pioneering anaesthetists would have had to make their own ether. TRUE/ FALSE
The first case of awareness under anaesthesia is also attributed to Pugh. TRUE/ FALSE
The first reported anaesthetic death in Australia is also attributed to Pugh. TRUE/ FALSE
It seems serendipitous that last week’s posts were obstetric related and today is the Queen’s Birthday holiday…
Queen Victoria was a relatively early adopter of anaesthesia and received chloroform anaesthesia for the birth of her 8th and 9th children, Leopold in 1853 and Beatrice in 1857. The chloroform was administered via an open drop technique, during the second stage of labour, with the aim of achieving semi-consciousness. The Queen is quoted as saying the chloroform was “soothing, quieting and delightful beyond measure”
It was James Simpson who, in 1847, first suggested the use of anaesthesia for labour. Initially obstetricians were almost universally opposed to the use of anaesthesia for labour, citing it as unnecessary for a natural process and concerned for the safety aspects.
John Snow, who anaesthetised Queen Victoria on both occasions, was a physician with a career spanning interest in anaesthesia. He experimented widely, on animals, using different inhaled substances in an attempt to find superior anaesthetic agents. He realised that the volatility of an agent declined as it was vaporised , due to the drop in temperature. Consequently he developed and early vaporiser, with a brass chamber which was immersed in water, to minimise temperature fluctuations. He appears to have been a man of great scientific rigour, which likely inspired confidence amongst the Queen’s physicians and eased the path for her to receive anaesthesia, when she and Prince Albert requested it. He was also a strong proponent of a doctor separate to the surgeon administering the anaesthetic. One of his major works On Chloroform and Other Anaesthetics and their Administration was published following his death is 1858. If you click on the title it will take you to a copy of the book, with William Morton’s name handwritten across the top!
John Snow made another great contribution to medicine as an epidemiologist. He was a believer that cholera was transmitted by contaminated water, contrary to popular belief at the time. Following an outbreak in London in 1854, he conducted an extensive epidemiological investigation tracking the details of victims and non victims to identify where they sourced their water. He identified the likely source as a pump on Broad Street, Armed with his research, he went to town officials and convinced them to remove the pump handle, making it impossible to draw water from the pump. The outbreak stopped almost instantly! It wasn’t until 1883 that Vibrio cholerae was isolated by Robert Koch and the means of transmission confirmed.
John Snow died age 45. Just imagine what he might have contributed to our speciality ( and others) if he had lived a long life……